Adding CKD to the Alphabet Soup: A Snapshot of Kidney Health in the LGBTQ+ Population
Authors: Leticia Rolón, Raymond K. Hsu
Journal: Journal of the American Society of Nephrology (2023)

CKD affects more than 30 million individuals in the United States and disproportionally affects older adults, non-Hispanic Black persons, and individuals with lower income and less formal education.1 While there is increasing understanding of racial-ethnic and socioeconomic disparities in the burden of kidney disease, there has been relatively little focus on the lesbian, gay, bisexual, transgender, queer or questioning, and other sexual and gender minority (SGM, or LGBTQ+) communities in kidney research. Even less is known on how these SGM identities intersect with known vulnerable groups to potentially influence kidney health. In this issue of JASN, Chandra and colleagues leveraged survey data from the 2014–2017 Behavioral Risk Factor Surveillance System (BRFSS) to compare the prevalence of self-reported kidney disease among adults aged 50 years and older who identified as LGBT+ (N=22,114) versus straight/heterosexual (N=748,963).2 In the study, "LGBT+" referred to individuals who identified as "lesbian," "gay," "bisexual," or "something else" across all gender identities, but did not include transgender and gender-expansive individuals who identified as straight. Self-reported kidney disease was defined as a "yes" response to the question "Not including kidney stones, bladder infection, or incontinence, were you ever told you had kidney disease?" They found that LGBT+ older adults reported higher rates of kidney disease than their heterosexual peers. This disparity was seen across nearly all sex, racial-ethnic, and age subgroups analyzed, with the most pronounced difference among non-Hispanic Black men (8.49% of LGBT+ men reporting kidney disease versus 6.74% of heterosexual men). LGBT+ adults were more likely to report poor health, depressive disorder, financial instability, and lack of health care coverage compared with their heterosexual counterparts. Using a series of logistic regression models taking into account sociodemographic factors, health behaviors, access to care, and key comorbidities (HIV, heart disease, and diabetes), the authors found that older LGBT+ men were still more likely than their heterosexual peers to report kidney disease (adjust odds ratio [OR], 1.3; 95% confidence interval [CI], 1.09 to 1.54), whereas the higher self-reported kidney disease prevalence was statistically attenuated among older LGBT+ women compared with older heterosexual women (adjusted OR, 1.16; 95% CI, 0.98 to 1.37).2 The study's main limitation is the self-reported nature of kidney disease, rather than objective measures such as eGFR and albuminuria. Ample data suggest overall low awareness of kidney disease, and the degree of awareness is strongly dependent on the wording of survey questions.3 On the basis of the limited phrasing of the "kidney disease" question asked in the BRFSS, the true prevalence of kidney disease in the LGBT+ population is likely significantly underestimated by the self-reported prevalence in this study. Nonetheless, the self-reported nature of kidney disease actually generates important questions on whether SGM individuals with CKD or specific LGBTQ+ subgroups may be more (or less) aware of their disease status. One could postulate, for example, that individuals actively receiving HIV treatment or pre-exposure prophylaxis for HIV prevention may have higher awareness of their kidney disease status because of the need for routine kidney function monitoring. Another limitation is that the analysis is anchored by sexual orientation and, therefore, excluded an important subgroup of transgender and gender-expansive individuals who identify as straight/heterosexual, who may share similar comorbidities along with social and behavioral risk factors with the LGBT+ individuals in the analysis. This methodologic choice is understandable, owing partly to the limited response options for gender identity in the BFRSS and sample size. An important future direction would be to better characterize self-reported and true kidney disease prevalence among the expansive universe of non-cisgender individuals.4 This would require better survey instruments with more diverse range of response options for gender identity (for BRFSS and other important health surveys frequently used in kidney health research, such as the National Health and Nutrition Examination Survey). Furthermore, estimating kidney function in the transgender population requires a critical lens at the appropriateness of the "female" sex coefficient in eGFR calculations, potential use of additional GFR measuring tools (e.g., 24-hour urine collections, measured clearance), and a better understanding on the effect of gender-affirming hormone therapy on body composition and filtration markers.5 Despite its limitations, the study provides an important, preliminary snapshot at (self-reported) kidney disease burden in the LGBT+ population. Across racial-ethnic, age, and education subgroups, older LGBT+ adults clearly have a higher self-reported prevalence—and likely higher true prevalence—of kidney disease compared with their heterosexual peers. The logistic regression analysis demonstrated that traditional risk factors such as race and ethnicity, socioeconomic status, age, health behaviors (smoking and alcohol use), and comorbidities can explain away some, but not all, of the disparity in kidney disease burden among LGBT+ individuals versus their heterosexual counterparts. A plausible explanation is that there is unaccounted risk factor shared among most—if not all—SGM individuals: mental stress associated with prejudice, discrimination, and stigma. The link between minority stress and physical health among SGM individuals is increasingly validated,6 and stress disorders are now known to be associated with CKD progression.7 For the nephrology community, acknowledging our LGBTQ+ patients as an at-risk group for CKD is a low-bar but important first step toward providing equitable care.8 Much more research is needed to understand the true burden of kidney disease across LGBTQ+ communities and intersectional identities, as well as to elucidate causative and potentially reversible etiologies. In addition, it is important to acknowledge that resources must be developed and readily available to assist and support the nephrology community in becoming informed on the breadth of diversity within the LGBTQ+ community to best address the needs of the patients, highlighting the need for and importance of ensuring a diverse workforce. Disclosures L. Rolón reports Consultancy: Glaxo-Smith Klein. The remaining author has nothing to disclose. Funding None. Author Contributions Conceptualization: Raymond K. Hsu, Leticia Rolón. Supervision: Raymond K. Hsu. Writing – original draft: Raymond K. Hsu, Leticia Rolón. Writing – review & editing: Raymond K. Hsu, Leticia Rolón.